Human Error in the Aviation Industry

Human Error in the Aviation Industry

The field of aviation is littered with horrifying and tragic losses. From the day men first made it flight nearly a century ago, up to this date, the field of aviation is plagued with horrible accidents. In order to monitor and regulate these incidents and oversee all aspects of actions done that are related to civil aviation in the United States, the Federal Aviation Administration (FAA), which falls under the United States Department of Transportation supervision, has created number of countermeasures. FAA is the agency that regulates and limits U.S. commercial space transportation and encourages civil aeronautics to develop new technology that would provide major help to the field of aviation (Burkhardt, 1967). The administration adopts a system of air traffic controls that would ensure and promotes aviation safety. It supervises all the actions around the field of aviation and promotes public safety such as control of errors in flying, aircraft noises and different environmental factors that are detrimental to the field of aviation.

By administering various things in the field of aviation in the United States, the rate of accidents in flying has greatly been reduced through the years. However, although the number of flying accidents has steadily decline in the past few years the cost both in expenses and the lives of people involved are still enormous. It is then important to know why despite of the FAA’s all out efforts and different protocols, programs, air traffic control systems and advancement in technological development in manufacturing aircrafts and equipments, accidents in the field of aviation is still inevitable.

During the early years of flying it would be understandable for people to blame accidents and death of airplanes personnel as results of mechanical failure of aircrafts. During those times, accidents were often attributed to poor and faulty mechanical functions of aircrafts and flying equipments. That was then, when science and technology has not yet made major leaps and bounds with regards to the aviation industry. Today, however, where aircrafts, airplanes, airport facilities and equipments have enjoyed the luxury of an era of much improved technological development, aircrafts can no longer be labeled as mechanically unsafe (Murray, 1997). In fact, observers see reversal of roles, where air craft personnel are now considered deadlier than the vehicle itself (Murray, 1997). Records show that from the series of these unfortunate accidents around 70 to 80 percent are results of human error (Shappell, 1997). However, the error is not confined to the mistakes made by the pilot or personnel on duties during the flight. Thus, it is wrong to attribute accidents solely as “pilot’s error”. Aviation accidents, caused by human error, are outcomes that results from numerous number of reasons (Heinrich, Petersen & Roos, 1980).

A particular framework that describes the origin and characteristic of human error is the ‘’Swiss cheese” model proposed by James Reason (Reason, 1990). According to him there are various levels of error that affects and influence each other. These interconnected levels of error comprise a human error. They all have contributions why accidents occur. The initial level of the error depicts and describes the Unsafe Acts of personnel which have direct impacts to the cause of accidents. In this level an action or the inability to perform such action from the operator, personnel or air craft’s pilot can become fatal, for it may directly be implicated to the cause of accident. Since actions or inability to perform the actions are the ultimate cause of the accidents, majority of FAA’s investigation is focused at this level. Investigations reveal various accidents causes; for instance aircraft’s pilot failure to maneuver properly in order to get past disturbances during storms and poor weather conditions and failing to appropriately scan and check if aircrafts equipments are in good conditions and functional before taking a flight.

Unsafe actions are categorized to two different categories – they are the errors and violations (Reason, 1990). Errors are considered as the representation of either the mental or physical activities of the personnel that due to unavoidable circumstances fell short in achieving the intended outcome. Men by nature are prone to commit errors, for this reason FAA’s databases are dominated by errors as cause of accidents. On the other hand, violations refer to the disregarding of existing rules and regulations that are FAA’s standards that provide safety of flight. It is the breaking of the laws and principle while the air craft’s personnel are fully aware of the consequences that may happen. Since disregarding rules often results to fatality, accidents caused by violations are less compare to accidents which are yielded by errors. A Prominent example of violation that had endlessly brought disaster in the field of flying is the continued disregard of pilots to weather bulletins. In an effort to fast track and avoid complications from their responsibilities, pilots and aircraft’s crews risk their lives and their passengers and still take off despite weather bureau’s warning. Low canyon flying is another example of a violation.

Unsafe actions can also be classified as skill-based, decision and perceptual error (Muchinsky, 1997). Skill based errors are those that that are link to the personnel’s failure due to their lack of capability. These includes breakdown in visual scan, unforced used and activations of equipments in the plane and inside the cockpit and misevaluation of steps and orders of flying and even emergency procedures. Skill based errors also include technique errors. Even if personnel and pilots excel in their study and are superior with their grades and have completed appropriate trainings, the way they carry and conduct themselves in the field is entirely a different story.  The execution of their strategies and modes of flying and how they handle the stress and pressure especially in case of emergencies are factors that determine human errors.

Decision errors, on the other hand refers to errors that are based from the crews judgments which at first they believed are appropriate but actually are inadequate (Muchinsky, 1997. They are intentional actions chosen to resolve problems, but unfortunately are insufficient. They are results of poor choices, problem solving and procedural error, pilot’s incompetence and lack of knowledge. Decision errors are also considered “honest mistakes”, as personnel who made such mistakes are committed in delivering high performance, but due to conditions mentioned above poor choices are made. One reason, perhaps why decision errors are made is the inability to properly comprehend the problem at hand (Heinrich, Petersen & Roos, 1980). Consider a pilot who has been separated from his family for months. On his flight back home he is confronted with disturbances from thunderstorms. He can either choose to take the longer route and fly around the thunderstorms or brace himself for impact and move directly towards the path of the thunderstorms. The latter scenario would present him intense thunderstorms in shorter period of time, while the first situation will offer him weaker disturbance but a longer period of time maneuvering around it. It is during such case poor decisions are made where inexperience, pressure from outside and poor training blurred our capability and capacity to make a sound decision.

Unsafe actions that fall under perception errors are mistakes committed from the inability to differentiate between reality and illusions. They occur when crews misjudged and misinterpreted the plane’s height, speed and surrounding areas especially during night time. Because of misinterpreted data, which is most common during poor weather and dark time, visuals illusions are created that leads to faulty information. Pilots then rely on their instincts trying to come up with the most appropriate guess. Furthermore, they rely heavily on instruments to monitor and track their movement rather than what is really happening on the outside world. However it is important to note that it is not the illusions or misinterpretations that are considered as the perceptual error. The pilot’s erratic responses to these illusions are the actions whish is categorize as the perceptual error.

However, although accidents caused by unsafe actions of personnel poses horrible effects, they, however, contributes in improving safety precautions and protocols in the aviation industry. By focusing majority of the accident’s investigation at this level, FAA is forced to identify and eventually able to find out latent or hidden failures that are link and perhaps sometimes the direct cause of accidents.  These latent failures are often overlook, but as investigators focused majority of their efforts on the unsafe actions by the aircraft’s pilot, these hidden failures, which may remained covered for days, weeks or even months are unearthed.

The hidden failures then lead us to the next level of human error as investigations reveal that unsafe actions are brought about by the condition, mentally and physically, of pilots and personnel during the flight. These conditions which affect their performances are referred to as the Precondition for the unsafe acts. The level includes conditions such as mental fatigue, pressure that builds from the hassle of work, poor coordination, communication and lack of efficiency in performing different tasks. The above conditions are grounds for which personnel, crews and pilots commit errors. It is understandable that once aircraft crews and personnel failed to communicate and coordinate properly with their co-personnel inside the plane and those in the airfield and towers, coupled with mental and physical fatigues, an incompetent decision may be formed together and a decision error then is made which in turn can be detrimental to the plane and the life of the passengers, as the flight now became prone to accidents.

Pre conditions for unsafe acts are subdivided into two groups; the substandard conditions of personnel and their substandard practice. The substandard conditions of personnel are composed of the mental and physiological state and the physical and mental limitation of the personnel. It includes the conditions of personnel during the flight. If pilots are suffering from mental and physical fatigue due to lack of sleep or sickness such as cold or fever, it would be certain that their performance during their flight would be affected. Timing, awareness, reaction time and ability to response accurately in an emergency would be compromised. The second group, substandard practices of the personnel is still divided into two categories; crew resource mismanagement (CRM) and readiness of the crew.

CRM refers to the failure of the personnel to work cohesively as a single unit (Orasanu, 1993). In the field of aviation two of the most important elements that separate accidents from happening and safety of flying are coordination and communication. First, personnel inside the plane must be fully aware of their roles and are able to back up and help each other. They should be well informed of every situation happening. Then, they should coordinate properly with personnel in the airfields controlling air traffics. Prominent numbers of accidents occur during take off and landing as a result of poor coordination among tower personnel and pilots. The 1972 crash at Everglade Florida was a direct cause of personnel miscommunication. Inside the plane a burn out indicator lamp was being trouble shoot. But as personnel fix the little problem, not a single crew member was monitoring the airplane’s altitude. As the altitude hold was inadvertently shifted, the plane slowly descended with the crews unsuspecting of the plane’s change in altitude, until the plane finally came crashing down.

The second subdivision, personnel readiness simply talks about the preparedness of the crew to work under extreme pressure. It also includes the illness that personnel are suffering which may affect their decision making. Rigid trainings are important aspects that determine personnel readiness.

Just as the first level of human error has provided helped in the aviation industry by tracing the roots of errors and creating counter measures to minimize the hazard of flying, preconditions for unsafe actions has also huge impact that greatly reduced the risks of traveling in air. First, it forces airline companies to review their existing protocols and training programs. They seek for better curriculum and improvement of their programs in order to produce personnel which are more qualified and adept. For instance in flight simulations can be made to let pilots become familiar of the problems that they may encounter, and in turn test their decision making while there’s still no lives at stakes.  Airlines are now also stricter with regards to accepting applicants. As a result, the standards of air craft’s personnel especially of pilots and those stationed in the air fields are uplifted. In addition, FAA’s policies are also reviewed and revised. They are now stiffer in implementing these rules and graver penalty awaits those who violate.

To fully understand how pre conditions for unsafe actions happen, we then will discuss the third level of human error. The third level is known as the unsafe supervision. Pilots and personnel often take the blame whenever accidents happen, but we failed to recognize that the chain of events is rooted back to the supervisory chain of command. If under the chain of command a problem exists, then the immediate supervisor is also at fault. The role of supervisor is very important at any field of operation, and in the aviation industry, where hundred of lives are at stakes in a single flight a minimal miscalculation and mistake could be disastrous.

Thus, there is no room for error. Supervisors then should be able to provide quality training, guidance, leadership, inspiration and motivation. They should also able to provide correct data and able to correct existing and known problems. For instance if a supervisor knew that a pilot is incapable in maneuvering the plane into safety, but still opt to let him fly, is tragedy waiting to unfold. The supervisor should have done something to remedy the dilemma such as extended training.

The Potomac River crashed (the river is situated just outside Washington) in January 1982 is a prime example of supervisory negligence (NTSB, 1982). A senior and very experience captain was paired with a junior weak co-pilot. Maybe in an effort to make the junior pilot more competent, he was paired with the more seasoned dictator captain. However, it was the reverse that happens. Poor coordination and communication resulted from the pairing, which is referred in the aviation field as the trans-cockpit authority gradient. Prior to their take off, the junior co-pilot noticed an abnormality in their engines instrument. Anxious of what he observed he continuously called the attention of his captain. The captain, however repeatedly rejected him, sensing he was paired with a weak compatriot. The rejection proved to be fatal as inadequate boost from the engine thrust pushed the plane to the Potomac River. The pilots may be held accountable, but more importantly it is interesting to note the crew pairing which is the tasks of the supervisory chain. If only their superiors had become more careful, then probably the incident may have been avoided.

Today, however supervisors have become more responsible with their actions as public has become more aware and conscious of traveling safety. The grave consequence of their actions also pushed supervisors to properly perform their roles. But still there are unfortunate cases where in supervisors are incapable to perform their tasks. It’s not always a case where supervisors are able to provide the necessary guidance, training that would equip his personnel with the important skills. But efforts in trying to improve supervisory roles could be seen as airlines have now become cautious.

The annals of the aviation field are indeed filled with terrible accidents. They are often caused by men’s negligence towards safety and inappropriate actions due to lack of proper knowledge, incompetence, outside pressure, poor decisions and ineffective training. However, although men’s error have accounted for a large number of accidents, they on the other hand, have served as eye opener for authorities to restructure existing laws and rules that govern safety in flying. They also pushes airlines company to develop additional polices that would be helpful in the industry. With proper implementations coupled with new technologies that greatly helped the industries such as Global Positioning System which is now applied in aviation, there is no single doubt that accidents caused by human errors and lapses could be significantly reduced or perhaps even be eliminated.

References

Burkhardt, R. (1967). The Federal Aviation Administration. New York: Frederick A. Praeger.

Heinrich, H.W., Petersen, D., & Roos, N. (1980). Industrial accident prevention: A safety management approach (5th ed.). New York: McGraw-Hill.

Muchinsky, P.M. (1997). Psychology applied to work (5th ed.). Pacific Grove, CA: Brooks/Cole Publishing Co.

Murray, S.R. (1997). Deliberate decision making by aircraft pilots: A simple reminder to avoid decision making under panic. The International Journal of Aviation Psychology.

National Transportation Safety Board. (1982). Air Florida, Inc., Boeing 737-222, N62AF, Collision with 14th Street bridge, near Washington National Airport, Washington, D.C., Washington: National Transportation Safety Board.

Orasanu, J.M. (1993). Decision-making in the cockpit. In E.L. Wiener, B.G. Kanki, and R.L. Helmreich (Eds.), Cockpit resource management. San Diego, CA: Academic Press.

Reason, J. (1990). Human error. New York: Cambridge University Press.

Shappell, S.A. (1997). A reliability analysis of the Taxonomy of Unsafe Operations. Aviation, Space, and Environmental Medicine.